The Alma Ata declaration of 1978 is a major landmark 3 –
page document that deserves re-reading Alma Ata
declaration . Alma Ata will be
mostly known for the rallying call of “Health For All by the year 2000”. In
addition to needing to redefine the target date there are a few other updates
that might be suggested, but the main
components of the document are as relevant today 34 years later. The foundation of subspecialites like “health
promotion”, “determinants of health”, and “population health” are clearly
visible in the text. Alma Ata was
predominately a call for reform of health care to ensure primary health care
systems were the foundation of national health systems.
While the document was often used to mobilize primary health
care systems in underdeveloped countries (barefoot doctors), there was a
subtheme for developed countries that health systems focused on secondary and tertiary
care were not sustainable either. How
prophetic that vision has turned out to be.
Enlightened jurisdictions began primary health care reforms
in the wake of Alma Ata. One can argue
on the relative success or failure of these efforts – but countries with more
focus on primary health care tend to have more health equity and are expending
less GDP than those that have invested in tertiary systems (see for example International
comparisons on Determinants of Health ).
Canada’s slow creep to reforming primary health care was in
part driven by the medical profession’s realization that the proportion of
medical graduates entering family practice was continuously eroding and had
slipped to only 1/3rd. The
other long standing driver is the history of and contributions of community health
centres and CLSC structures.
There came a series of investments in the late 90’s of the
typical Canadian pilot projects, atypically followed by further investments to
disseminate and implement the knowledge gained. Perhaps not the smoothest of transitions,
and since provinces could choose their reform model, the diversity was
notable. Many provinces went the route
of “building” primary health care with some shining examples but minimal
success in changing the whole system. Alberta more broadly stimulated joint ventures between physicians and health regions with mixed
success. Ontario stimulated physician to
reform through “incentivizing” and supporting expansion of an already robust
community health centre infrastucture.
Here we are some 15 years into the primary health care
reform process and the volume of information gained on what works and what
doesn’t is deafening. Or, perhaps we
just can’t hear it. Or, perhaps it wasn’t well evaluated, or.......etc. CIHI was supposed to lead the evaluation,
and that toppled in the early 2000’s with hardly a peep , does anybody know
what happened? The lack of formal evaluations is appalling to say the least given the hundreds of millions invested, it rivals regional health authority reforms in bureaucractic decision making without rigorous evaluations.
At last, something concrete, although perhaps biased. From the Institute for Clinical
Evaluation Studies in Toronto www.ices.on.ca comes a comparative analysis based on the multiple primary care
models[i] that co-exist in Ontario. The problem is the study was commissioned by
the Association of Ontario Health Centres and some of the
measures used are not as forthcoming in openly comparing the different models. The
long list of limitations of the data speak to some of the assumptions and
problems. CHC enrollees
represent only 1% of the provincial residents. The presented data strongly support
CHCs as a preferred model of care.
However, at last something that uses the wealth of
administrative data sets to do comparisons of persons using the various different
models. There is a reasonable set of references that can be accessed with additional recent comparative
statistics. Watch for the peer reviewed
materials, but there is finally some progress on trying to answer the question
of how to improve the primary care system in Canada ICES
comparison of primary care models.
[i] Purists can argue for days on the
differences between primary health care and primary care. The two are intertwined and reform in one
cannot proceed without the other.
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